….Working together to work wonders
N 3340 Health Assessment
Specific Criteria for Comprehensive Skill Validation
ACTIVITY
Findings
GENERAL SURVEY
Vital Signs
o Perform vital signs prior, review them, and
document them
AIDET & Hygiene
o Acknowledge the patient
o Introduces self
o Duration
o Explanation
o Thank you
Mental Status
o Assess orientation to person, place, time, &
situation
Pain assessment
o Ask about pain from 0-10 point scale
o Perform COLDSPA as indicated
SKIN, HAIR, AND NAILS
Inspect and palpate skin and nails
o inspect the skin as you go down
o comment on skin color, freckles, abrasions,
rashes, moles, skin integrity, edema, &
lesions (verbalize this)
o assess nail shape, color, & cleanliness
(verbalize this)
Assess skin turgor
o assess over the clavicle
HEAD, FACE, & NECK
Inspect skin.
Inspect and palpate cranium, hair, and scalp
Assess range of motion
o Move ear to shoulder; rotate head sideways;
chin to chest; and chin to ceiling
Inspect face
o Assess symmetry of eyes, face, nose
(verbalize this)
Test Cranial Nerve V, VII and XI
o CN V: ask the patient to clench their teeth;
palpate temporal and masseter muscles
o CN VII: ask the patient to smile, frown, close
eyes tightly against resistance; lift eyebrows,
puff out cheeks and then push against them
o CN XI: push sideways from the head against
resistance; push the shoulder up (shrug)
against resistance
Inspect neck for jugular vein distention &
visible pulsations
Revised: 9-25-2017 TBM
….Working together to work wonders
o
Verbalize what you are doing
o JVD is/ is not observed when neck
is assessed in semi-fowler’s position
at a 30-45º angle.
o Turn the patient’s head away from
the examined side, direct light onto
neck to highlight pulsations (located
overlying the sternomastoid muscle
or at the sterna notch)
o When patient is raised to 45 degree
or higher position, there should be
no evidence of JVD
Auscultate & palpate carotid arteries
o Palpate the carotid arteries separately
bilaterally.
o Auscultate the carotid arteries bilaterally.
o Listen with bell
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EYES
Inspect eyes, conjunctiva, and sclera
o Lower the lower eyelid to inspect the
conjunctiva
o Inspect the color of the sclera (verbalize what
is being done)
Test vision (CN II)
o Test visual acuity using the Snellen or Jaeger
card
o Snellen: position patient 20 feet
from the chart. Shield one eye at a
time during the test. Ask person to
read the smallest line of letter
possible.
o Jaeger: Hold card 14 inches from
the eye. Test each eye separately
Test extraocular movement (CN III, IV, & VI)
o Have the patient move the eyes in the 6
cardinal fields assessing for nystagmus
o Ask pt to hold head steady and
follow movement of your
fingers/pen/penlight only with eyes,
hold object at 12” move to each six
position, hold for momentarily, then
back to center, go clockwise
Revised: 9-25-2017 TBM
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Conjunctivae are pink & clear over the lower lids

Sclera is China white

Snellen: “normal” 20/20
o Right eye vision:
o Left eye vision:
Jaeger: “normal” 14/14
CN II (optic nerve) intact
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
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Pt was able to parallel track penlight w/ both eyes
No nystagmus noted OR mild nystagmus at extreme
lateral gaze
CN II, IV, & VI (oculomotor, trochlear, & abducens)
intact
….Working together to work wonders
PERRLA (Pupils Equal, Round, & Reactive to
Light, & Accommodation)
o Turn the lights off
o Use the pen light and shine it toward the R
and L eye twice assessing direct &
consensual light reflex
o
Use the penlight to get the patient to look
away far at the pen light and then move the
pen light toward their eye looking for
constriction of pupils



Patient has direct & consensual constriction
Pupils ARE equal, round, & reactive to light &
accommodation both direct & consensual
Pupils ARE equal, round, & reactive to light &
accommodation both direct & consensual
EARS
Inspect and palpate shape and position
o Look at the ears – skin color &
o
shape
o Palpate the ears (ask about pain)
o
Pull the ear up and back and assess for pain
in the ear canal
Inspect external ear canal
o Look in the ear canal (can use a penlight)
Hearing Acuity (Whisper Test - CN VIII)
o Cover one ear or have patient place a finger
over tragus pushing it in and out; hold the
hand against the mouth so the patient cannot
read, and whisper a two syllabus word
(baseball, Tuesday, fourteen, soccer, etc.)
o Stand 1-2 ft behind & lateral to pt,
cover own mouth as you whisper 3
RANDOM 2-syllable words; have pt
press on tragus to occlude opposite
ear (the one not being tested). Have
pt. repeat back what was whispered
NOSE, MOUTH, and THROAT
Inspect nose
o Assess skin of nose & mouth
o Use a penlight to look in the nose for edema,
deviated septum, or bleeding
Assess patency of nostrils (CN I)
o Have the patient close their eyes, occlude
one nostril at a time & smell the scent
o Push each nasal wing shut, ask pt
to sniff inwards
Revised: 9-25-2017 TBM
….Working together to work wonders
o
Patient to close eyes, occlude one
nostril and present a smell. Repeat
with other nostril
Inspect mouth
o Assess for color of mucous membranes,
lesions, bleeding, tonsils, uvula, soft & hard
palate, & condition of teeth (verbalize this)
Inspect tongue
o Inspect moisture, grooves, color (verbalize this)
Test Cranial Nerves IX, X, and XII
o CN IX & X: have the patient say “Ahh” and inspect uvula.
Assess quality of voice
o CN XII: stick out their tongue
o Also ask patient to say “light, tight, dynamite”
RESPIRATORY*
o Inspect respiratory rate, rhythm, & depth (verbalize this)
o Inspect skin covering anterior & posterior chest.
o Assess use of accessory muscles. (verbalize this)
o Assess size and shape of chest. (AP: lateral dimension)
(verbalize this)
o Assess position the patient is in (verbalize this)
o Assess oxygen saturation, as appropriate
Palpate symmetric chest expansion
o Placing the hands with your thumbs at the T9-10 level
- beside the spinal column. Slide your hands in to pinch up a
small amount of skin and ask the patient to take a deep
breath. Inspect for movement of your thumbs as the
patient inhales.
Auscultate lung fields
o Ask the patient to breath in and out of the mouth-not
deeply
o On the posterior chest listen to 10 spaces bilaterally with 1
breath/space
o On the anterior chest listen to 5 spaces bilaterally with 1
breath/space
CARDIOVASCULAR & PERIPHERAL VASCULAR*
Auscultate heart sounds
o Auscultate the heart in the aortic, pulmonic, Erb’s point,
·
tricuspid, & mitral areas. Focus on the S1 and S2 heart
sounds
Revised: 9-25-2017 TBM
….Working together to work wonders
o
Palpate the radial pulse as you listen to the mitral area
(apical pulse) for the presence of a pulse deficit.
o Listen for murmurs
o Use bell of the stethoscope
Palpate pulses
o Radial, brachial,
o Dorsalis pedis
o
Posterior tibial bilaterally
o Perform as you progress down
Test capillary refill
o
o
Assess the capillary refill of the fingernails
Assess the capillary refill of the toe nails when you have
worked your way down
Inspect for edema
o Assess for edema especially in the pre-tibial area, ankles,
& feet
ABDOMEN
Inspect, auscultate and palpate
o Inspect the skin color; scars; lesions &
rashes; contour
o Inspect pulsations on the abdomen.
Revised: 9-25-2017 TBM
….Working together to work wonders
o
Auscultate bowel sounds in all 4 quadrants.
Begin with the RLQ unless this is where their
pain is and move clockwise.
o Light palpation watch the patient’s face the
entire time you are palpating
NEUROLOGIC CEREBALLAR
Assess finger-to-nose coordination
o Have the patient close eyes & move finger to
nose
Gait
o Have the patient: walk across room
o Walk heel to toe
o Walk on toes
o Walk on heels
MUSCULOSKELETAL
Romberg test:
o Ask patient to have feet at a comfortable
width; close their eyes x 20 seconds, assess
for swaying
o Swaying = positive Romberg
Assess active range of motion
o Assess the skin covering the joints
o Shoulders:
o Adduct and Abduct (forward,
backward, crossing in front
extending out to side)
o Internally Rotate
o Externally Rotate
o Elbows
o Flex and extend elbows
o Pronate and supinate both arms
o Wrists
o Flex and extend wrist
o With palms down deviate inward
toward the radial bone, and outward
toward the ulnar bone
o Fingers
o Extend and flex fingers
o Adduct and abduct the fingers
o
Flex fingers into a fist
o Touch each finger to the thumb and
thumb to the base of the little finger
o knees,
o Flex and extend each knee
o Ankles
o Dorsiflex the foot
o Plantar flex the foot
o Eversion and inversion of both feet
o
o
Perform as you are progressing downward
Ask patient to flex, extend, and rotate based
on part of body
Assess vertebral column for Anomalies
Revised: 9-25-2017 TBM
….Working together to work wonders
o
Inspect and palpate as the patient flexes
downward from the waist
Revised: 9-25-2017 TBM
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